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General NPI Number Information
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NPI Number | 1922480383
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Entity Type | Organization
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Legal Business Name | PROACTIVE HEALTH CHIROPRACTIC, CORP
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Dates
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Enumeration Date | 06/22/2015
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Last Update Date | 06/22/2015
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Provider Practice Location Address
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Address Line | 23801 E APPLEWAY AVE 110
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-9687
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Country | US
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Telephone | 507-251-5248
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Fax |
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Provider Business Mailing Address
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Address Line | 4915 N VISTA GRANDE DR
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City | OTIS ORCHARDS
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State | WA
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Zip | 99027-5001
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Country | US
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Telephone | 507-251-5248
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SAMUEL NELSON
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Credential | D.C.
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Telephone | 507-251-5248
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH 60570733
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License Number State | WA
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